Dermatology in Ghana: a retrospective review of skin disease at the Korle Bu Teaching Hospital Dermatology Clinic

Introduction Ghana is currently developing its provision of dermatology services. Epidemiologic studies of the skin diseases seen by Ghanaian dermatologists are needed to guide these efforts. We aimed to describe the skin conditions seen by and management practices of Ghanaian dermatologists in a specialized clinic. Methods We conducted a chart review of new patients presenting to the Korle Bu Teaching Hospital dermatology clinic during 2014. Results Among the 529 patients studied, 700 discrete diagnoses were made. The most commonly diagnosed skin conditions were infections (24.6%) and dermatitis (24.6%); atopic dermatitis (8.4%), acne vulgaris (5.3%) and scabies (5.1%) were the most common specific diagnoses. Among infants, children, and adolescents, the most common diagnosis was atopic dermatitis (31.7%, 30.0%, and 14.9%, respectively). Acne vulgaris (12.0%) was the most common skin condition diagnosed in young adults. Irritant contact dermatitis (6.9%) was most common among adults. Lichen planus (9.9%) was the most commonly diagnosed skin condition in the senior population. Diagnoses made by dermatologists differed from the referral diagnosis documented by primary care providers for 65.8% of patients. The most frequently recommended treatments were antihistamines (47.8%) and topical steroids (38.4%). Only 18 diagnostic biopsies were performed. Conclusion Our study summarizes the skin diseases seen and management practices of Ghanaian dermatologists in a specialized clinic at a large public teaching hospital. The results of this study can help to guide future dermatology education and development efforts in Ghana.

International public health initiatives have been created to reduce the prevalence of high-morbidity skin diseases such as Buruli ulcers and lymphatic filariasis in Africa [11,12]. Epidemiological studies of the burden of skin disease in Africa have helped shape directions for physician training as well as public health campaigns. Ghana is needed, as a study of skin conditions at a dermatology clinic in Ghana has not been conducted in over 20 years [13,14]. Therefore, we conducted a retrospective review of skin conditions seen in the dermatology clinic at KBTH. Our study describes the spectrum of skin disease seen by dermatologists in a specialized dermatology clinic at a large public teaching hospital in Ghana.

Methods
We performed a retrospective chart review of all new patients presenting to the KBTH dermatology clinic over a 1-year period from January through December 2014. This study was approved by the

Results
During the study period, 631 new patients were seen in the KBTH dermatology clinic, of which 529 had charts available for review ( were student (22.8%), trader (14.8%), and service industry employee (7.3%). The geographic distribution of patient-reported hometowns is shown in Figure 1. A total of 700 discrete diagnoses were made during the study period (full classification of diseases can be viewed in Online Resource 1). There were 165 patients diagnosed with more than 1 condition. The most commonly seen disease categories were infections (24.6%) and dermatitis/eczema (24.6%). Malignant and pre-malignant conditions were rare (2.8%).

Discussion
Until recent years, Ghana lacked a sustainable workforce of dermatologists and had limited access to resources necessary to providing quality skin care. In order to facilitate Ghana's recent efforts to improve its local dermatologic capacity, we described the spectrum of skin disease seen in a specialized dermatology clinic at the largest public teaching hospital in Accra. Our results provide an updated overview of the main skin diseases managed by Ghanaian dermatologists, and may be used to guide future dermatology education efforts and public health campaigns. Additionally,, our data can help to train primary care physicians in recognizing and treating the most common dermatologic conditions, as they currently manage the majority of skin complaints in Ghana [14]. While no studies of pediatric skin disease seen in specialty clinics are reported in the literature, there have been a few studies conducted of the prevalence of specific skin conditions in Ghanaian children-including acne, tinea capitis, and eczema [4,[15][16][17]. We found atopic dermatitis to be the most commonly diagnosed condition at the KBTH clinic. While our observation of atopic dermatitis was similar to that of Addo et al.
(16.5%), the previous study found contact dermatitis to be much more common (27.6%) [13]. Doe et al. found dermatitis to be the second most common diagnosis (18.4%), but this was mostly due to irritant contact dermatitis and seborrheic dermatitis [14].
Acne vulgaris comprised 5.3% of skin diagnoses reported in our study. Similarly, Doe et al. found that acne vulgaris accounted for 4.6% of visits [14]. While Addo et al. found acne vulgaris to be relatively uncommon (2%), the author speculated that the actual incidence of acne vulgaris was higher than that reported because Ghanaians perceive acne as a normal feature of adolescence and rarely seek medical treatment [13]. The increased incidence of acne Clinical diagnoses are favored, while biopsies are reserved for cases where there is significant diagnostic uncertainty or when the condition does not respond to empirical therapy. Another important logistical consideration in Ghana is that payment for medical services-both the physician visit and any ancillary laboratory testingmust be made at the time medical care is received. Similarly, medications are purchased out-of-pocket and the available formulary is limited; inexpensive and readily-available formulations are therefore preferred [23]. Finally, at KBTH connective tissue disorders are primarily treated by rheumatologists rather than dermatologists, leading to the misleadingly low prevalence of these disorders in our data. Our study demonstrates that Ghanaian dermatologists provide extremely valuable expertise, as approximately 65% of diagnoses made by the dermatologists at KBTH differed from the referring diagnoses listed by primary care physicians. The high rate of diagnosis change also suggests a potential opportunity for education at the primary care level.

Indeed, results of similar epidemiological studies in sub-Saharan
Africa have been used to create a management algorithm for common skin diseases for use by local primary care physicians [24].
Similarly, the low number of biopsies observed during the study also highlights an opportunity for additional education in dermatopathology. There were several limitations of this study to consider. First, the source of our data was patient records of a specialized dermatology clinic at a tertiary care hospital. This type of study carries the inherent selection bias of patients that actively sought out specialty care for their conditions, and does not represent the incidence of skin disease throughout the country.
Additionally, KBTH is one of few hospitals in Ghana with multiple practicing dermatologists and a Department of Dermatology, as well as the only hospital with a dermatology fellowship training program.
Therefore, our may not be generalizable to all dermatology clinics in Ghana, especially in rural areas where resources may be scarcer.

Conclusion
Twenty-five years ago, dermatology in Ghana was considered to be "a hobby of just any physician" [13].

Competing interests
The authors declare no competing interests.  Table 1: Patient demographics